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AS BUILT SANITARY SYSTEM REPORT
OWNER IS,4
ADDRESS Z
/tjDsoN
SUBDIVISION / CSM T KA(~
# S' LOT # 3'/
7~
SECTION L _T 't. ' N-R
-jTown of N y D s a
ST. CROIX CO CONSIV
Col-nE-S~+~ PLAN VI A
W THING W~THIN 100 F T OF SYSTEM
1 4 #,e,4GE
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S S' INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover-
BENCHMARK: -of 0;7 1 -?I,-4E AT Aral f04NEt s E/_ /0000
ALTERNATE BM: To P o F (-FpJs Fvu N!D AI T ON E/.
IC T / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W F7 1 S E 2. Liquid Capacity:
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House Other
I
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION~::
PLUMBER ON JOB: mohw"` r~.~q ~ w e
LICENSE NUMBER: ~f'~-sue O ~a O
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Permit ldgr's NaCJme- ❑ City E] Village Cl Town of: State Plan N
MILL , 7{
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA Z Zp'
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~S Benchmark
Dosing
Aeration Bldg. Sewer
H ng St/,~f Inlets
TANK SETBACK INFORMATION St/ 110 Outlet 76
TANKTO P/L WELL BLDG. vent to ROAD Dt Inlet
Air Intake
Septic 6, NA Dt Bottom
Dosing NA Header 12'92.9Z'
Aeration NA Dist. Pipe
Bot. System s 93
Holding
F71 90,
PUMP/ SIPHON INFORMATION Final Grade /e. '
._r..
Manufa Demand`-''
Model Number M
TDH Lift F Ion I Syestem TDH Ft
Forcemain.- ength Dia. FFii Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width r Lengt}h, No. Of Trenches PIT No. Of Pits In uid Depth
DIMENSIONS s YS ~ DIMEN I
f~ SYSTEM TO P/ L BLDG WELL LAKE / STREAM CHING
SETBACK CHAMBER
i Model Number:
INFORMATION TypeOf k ColUiZ
System: tr&,AXS 60 /Jf~ a OR UNIT
DISTRIBUTION SYSTEM
Header / « Distribution Pipe(s) ~r x Hole Size x Hole Spacing Vent To Air Intake
Length--/-/-: Dia_ Length ~ Dia. Spacing (O
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S ms n
Depth Over Depth Over xx Depth Of xz Seeded /Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Hudson.12.29,/.19. NW, SW, Lots 334, yAntler Ridge
u " ire G~(~ ~ yam- 411 e
Plan revision required? ❑ Yes No
Use other side for additional information. /02 9 f M9
SBD-6710 (R 05/91) Date Inspector's Signa re Cert. No
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
Cot O
than 81/2 x 11 inches in size. -ST. /X
• See reverse side for instructions for completing this application State Sanitary Permit Number
aS'9V o -
5-The information you provide may be used by other government agency programs Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)).
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name - Property Location
5514 47 1011~/LL 114,40- 0/4 SG/1/4, S ( Z T Z , N, R/q E (o
Property Owner's Mailing Address Lot Number Block Number
®
City, State / Zip Code Phone Number Subdivision Name r CS^M Number
11. TYPE F BUILDING: (check one) ❑ State Owned ❑ !tv Nearest Road
.S~r7 C- E
Public 1 or 2 Family Dwelling - No. of bedrooms Town Town OF LL 0Q ANRrK A ID
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo O ZO - 3~ / - 7 a
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify
1V. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. % New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------System System Tank Only______________ Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12),Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System €lev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 0/ 93•S Elevation
S c 3S3 7So - $ -''Z 9 Z, S Feet 99.00 Feet
VII. TANK Capacity
in gallons Total
lons Tanks Site gFiber- lass Plastic Aper.
INFORMATION Gallons Existing Manufacturer's Name Concrete Con Steel
- glass App.
strutted
Tanks Tanks
Septic Tank or Holding Tank SLS l ~E~ S I~ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (N tamp" MP/MPRSW No.: Business Phone Number: Ar r,
/►~I ► k E 1O ~I GL ; s • 0,3 Soo 3 8'G -dG9 Z,.
Plumber's Address (Street, City, State, Zip Code):
w iLL G,-41jg-
.7 ,y v v so X w l
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Age Sig ture (No tam
Approved ❑ Owner Given Initial ~y Surcharge Fee)
Adverse Determination ll
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a iicensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
iI. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, recur nection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes,- soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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SANITARY PERMIT APPLICATION Bureau o oand ff Building safety uildildinWater System!
g Water 201 E. Washington Ave.
In accord with ILHR B3.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. 15
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owne Name / Property Location
,t l(~iG 4 IYGA14 SW 1/4, S lZ_ T N, R E (o
Property Owner's Mailing Address Lot Number Block Number
oX*~ 13
City, State Zip Code Phone Number Subdivision Name or CSM Nu b r
1-4/050 /J w 1 ( Z) --17W -
F. TYPE OF-BUILDING: (check one) ❑ State Owned o ity l Near st Road D
Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town of 0
I` lb (0
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo G -1( 3 _ 7 C7
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1- New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank OnlyExisting System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ,Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq- ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min./inch) Elevation
:5 S 00 , 0/ S Feet tq ,3,7 Feet
Capacity
VII. TANK in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete stun- Steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank W ISS0, ❑ ❑ ❑ ❑ ❑ _+JZ] Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
A / 15
L L `~~to 9L
AA
Plumber's Address (Street, Clty, tate, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved San tary Permit Fee (includes Groundwater Date Issue Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
C/S
I Adverse Determination _4 A,
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05194) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V Type of system. Check appropriate box depending on system type.
VI_ Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance.curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of
J,.~bor,ar4 Human Relations
17S'visisn of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
. COUNTY
Attach complete site plan on paper not less than 8,141*- es in size. Plan must include, but IS`T (f 1y
not limited to vertical and horizontal refegncint, @ )1 Mi nd % of slope, scale or PARCEL LD. #
dimensioned, north arrow, and location'e`o nea
APPLICANT INFORMATION-PLE AF `L OR N REVIEWED BY DATE
PROP RTY OW R: ,r, PROPERTY LOCATION
SW GOVT. LOT (,`j 114 114,S 2 T 2.9 ,N,R lp
1 E (or) W
yh M1 t ! ? ~
10 35
PRO ERN OW RR''::S MMA,I~LIN~igDDRE " T BLOCK # SUBD. AME OR CSM
,Qp Z~7 F etc K 1C~O t~ t Y A1~f r Y 1+~1i C
CITE ITATE ' r ZIP Fp_I#a~tg181 ❑CITY 4fWGE OWN NEAREST ROAD/ .
K New Construction Use flkj Residential7tMitkof ooms ON 1e, [ ] Addition to existing building
j ) Replacement Public or commercial describe
Code derived daily flow gpd Recommended design loading rate - bed, gpd/ft2 0,1 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 61 trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as ref red to site plan benchmark)
Additional design / site considerations EVat rso~~ ft 'T Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL rRUND 1 ROUND PRESSURE T-GRADE SLY TEM IN FILL HOLDING T NK
U =Unsuitable fors stem S ❑ U ® S El U WS El U S ❑ U as ❑ U ❑ S 14t)
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxbry Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
.4 nv}
n.•
r 7~► G~ 2F O . q 0.5
32-91 16-V P-414
Ground 09r yVt - 67 Q,
elev.
%5 ft.
Depth to
limiting
fa/gto ~
Remarks:
Boring # '
Q -13 /byik 3 SL O r rh Cw ? 64 6.<
3-117 OYK4,14- 0,-7 Y (J r n'i 6.g
Ground
elev.
mg,16 ft.
Depth to
limiting
"*7 factor~
T
Remarks:
CST Name:-Please Print ,4 ~ N Phone:
Address:
Signatur Date: Z! CST Number: "~434-1
U k-)
PROPERTY OWNER S4nl #JILLC)k SOIL DESCRIPTION REPORT Page 2 of,
PARCEL I.D. # p
t
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Barry Roots GPDt
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed p~ /OY 3 SL, l rn Cr rh Gw Z p.4 3
9ZZ 10Yk 4 5 Z 1 m cr yn~r Cw Z 6A 6
Ground - / /DYk 44 S r Y)l 0~1 61
elev.
/OOA ft.
Depth to
limiting
f~t~3
Remarks:
Boring #
0-17-2- /W&Z - 1 m cr 0, 6
X2-u 0`Iv2 4 S r IyJ 62 0.7
Xl~
Ground
elev.
JoZ,IZ ft.
Depth to
limiting
f for
Remarks:
Boring #
A njo /w s~ lrncr rnC- cw 2~Ogd~
- L rh s b n,r W 0
S> -2-7 10k4b
Ground 9Z 1-7-111 l6-lie 4 4 S V- rn a
elev.
Depth to
limiting
yf~toZS
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 5,+m
MAILING ADDRESS 5:0 K
PROPERTY ADDRESS So ~ .441'rZ
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE VD-5 ? N (..Aj I )eD 1%
PROPERTY LOCATION X16~J 1/4, OJ 1/4, Section Z T ,;L g N-R 19
TOWN OF lJ~ O A ST. CROI K COUNTY, WI
SUBDIVISION 7_#1yNE Y - LOT NUMBER_
CERTIFIED SURVEY MAP -5'317 y Z , VOLUME , PAGE LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
91
SIGNED: ~~v
Q_j
DATE:
25
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, Wl 54016 11/93
' S T C - 100
• This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office' with the
appropriate deed recording.
owner of property SA rYl M lcL~/~
Location of property d/w 1/4 Sw 1/4, Section / Z ,T L' N-R ~9 W
Township UD S d N Mailing address I3oX3r z Z
(-f 0-,SC5 -y w 1 s 1(0 i~,
Address of site_ So AW-Z r P./p6.6 QD,#O
Subdivision name Try #F-V 4to-F- Lot no..3~
Other homes on property? Yes/C No
Previous owner of property -Po'fr i z- k- S NA N
Total size of property a, 4I #-ee x.-7
Total size of parcel 2, (o I fie,
Date parcel was created 7-1 _513
Are all corners and lot lines identifiable? ,,e Yes No
Is this property being developed for (spec house) ? Yes No
Volume /n 3/ and Page Number 5~s-' as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. So 44$.SS- , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
sa yy ss
S ture f Applicant Co-Applicant
Date of Signature Date of Signature
• DOCUMENT NO. STATE BA W[SCONS[ OR3f 1- 19ei THIS S.-^C9 RefeRVSa FOR 118COMIN0 DATA
ARRANTY 0 D '
5048550"L 103JME 456
~_C1STER'S OFFICE
This Deed, made between
Randall W. S nan and Patricia E. S nan,
.....................Y..-... X..-....... Zec-d f rRowed `i
husband---and. wife...--...-- 1
c
i .Grantor. SEP 1~ 1993
and: _Sam E. Mi.l::er...- a _snqle person 1 ~l 10:45 p ~A~-
~P~+o•+-,Q~
Grantes, R'ft'" 't
1 Witnesseth, 'that the said Grantor, f r a valuable consideration..-_..
t,. Randall W. Synan and Patr~cia E. Synan
conveys to Grantee the following described real state in St . CrO X . RATUR14 RaruRN TO
County, State of Wisconsin:
Q.
•t 1 Tax PPand Me: - ;
" The SE1/4 of NE1/4 of Section 11; the SW1/4 of NWl/4, the N1/2
of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of
NW1/4 except the East 74 feet thereof, all in Section 12; all in
YI Township 29 North, Range 19 West, Tovn of Hudson, St. Croix
' County, Wisconsin. FF
AND Fn
A A parcel of land located in part of the NE1/4 of SE1/4 of Secti11, Township 29 North, Range 19 West, Tovn of Hudson, St. Croix
County, Wisconsin further described as follows: Commencing at the
E1/4 corner of said Section 11; thence S89 30100"W, along the
North line of the SE1/4 of said Section, 1212.32 feet to the point
'j of :.eginning; thence continuing S89 301000W, along said North line,
66.00 feet; thence SOO 28103"E, 500.00 feet; thence N89 30100"E,
along the North line of Certified Survey Map filed in Vol. "30,
Page 722, 38.08 feet; thence N00 11133"W, 150.00 feet; thence
N03 58134"E, 351.07 feet to the point of beginning.
This ..........1A... T.%Rt_... homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances tuereunto belonging;
And..... U]f 441,1-VI.---$y-nan-- and--Patricia-. E,- S nan
warrants that the title is good, indefeasible i-- fee simple and free and dear of encumbrances except
easements, restrictions and rights-of-vay of record, if any.
and will warrant and defend the same.
Dated this day of Aug.14s. r 19
G7!Y!d's~JY G~ ~l!~~~ ...(SEAL) !2lG&kF!!-..4:...r.49t✓........................... (SEAL)
• Randall W. Synan Patricia Synan
•
..........................................•-----............-_(SEAL) __..........._.........................._...........................(SEAL)
• • i
t. AUTHNNTICATION ACZX0WL=DQKZXT
Si tares
gnu O STATS OF WISCONSIN
II
z 1111116
St Croix
~ authenticated this ........day of 19 _p..~-.n- cam before an --....dq of ;
.5
this
e August . ty........ the aboeo named
I~ Randall -M. S rian;-..pat_ric-ia..
............................X
• X
TITLE: MEMBER STATE BAR OF WISCONSIN Syrian - - _ -
(If not, i
AM..OY.
authorized by I 706.06• Wis. State.)
to me known to be the person .0..... .Y 5 e I
I~
going instrn nt and 7 n i
THIS INSTRUMENT WAS DRAFTED BY
'
r Rristina Ogland ,
At-cornep--a-t--LaW............................... a Alice Joy o ors
• .
. Notary Public County, Wis.
r (Signatures may be authenticated or acknowledged. Both My Commission is permanent. f not, state exp' stion
are not necessary.)
date : lA.j~.I.)
•N•m.a of persom sienlne is any rapacity should be tsp•d or printed below their sienatu.es. j
r 1
WARRANTT OILED STATE SAi Or WISCONSIN Wisconsin local Black Co. Inc.
FORM No. 1 - Ife1 Milraukee- WIS.
DOCUMENT NO. STATE BA F WISCONSI ORM 1-1981 THIS S+ACr rrsrrvrO FOR RrcOR01RO 7ATA
ARRANTY D D '
504855. o1. ifi<3iftGE 45fi
CiST-4'S OFFICE
This Deed, made between
Randall W. Synan and Patricia E. Sxnan,
nec'~ sbr Reowd
husband and . vi fen...
z
Grantor, 1 SEP 1993
and.....Sam...-'...~ 1_.,•er... .........n91e...I..ersori......._.. I it 10:45 `*-"'~A.- M
*C.
. Grantee, L a-~ls~e.:# a.oe
Witnesseth, That the said Grantor, f r valuable consideration......
.ndal.
. r..~. ci a E. Sy.nan
. . . Ra.
.l W.....S.i{/n..a and..
.Pat.
.
.
. .
..................a................... a..... Rerux" To
conveys to Grantee the following described real estate 'in St . Cro x
County, State of Wisconsin:
Tax Pared 420:
The SE1/4 of NE1/4 of Section 11; the SWl/4 of NW1/4, the N1/2
< of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of
NW1/4 except the East 74 feet thereof, all in Section 12; all in
.y Township 29 North, Range 19 West, Town of Hudson, St. Croix
County, Wisconsin. .n.0 AND Tn-t
A parcel of land located in part of the NE1/4 of SE1/4 of Secti11, Township 29 North, Range 19 West, Town of Hudson, St. Croix
County, Wisconsin further described as follows: Commencing at the
E1/4 corner of said Section 11; thence S89 30100"W, along the
North line of the SE1/4 of said Section, 1212.32 feet to the point
'j of Beginning; thence continuing S89 30100"W, along said North line,
66.00 feet; thence SOO 28103"E, 500.00 feet; thence N8Q 30100"E,
along the North line of Certified Survey Map filed in Vol. "36,
Page 722, 38.08 feet; thence N00 11133"W, 150.00 feet; thence
N03 58134"E, 351.07 feet to the point of beginning.
This ..........AM... rASlt.... homestead property.
I (is) (u not)
Together with all and singular the hereditaments and appurtenances tuereunto belonging;
And.....RWRIA l...W:....$_VPA}...and•.Pat .i ia.. E Synan
warrants that the title is good, indefeasible in fee simple and free and dear of encumbrances except
easements, restrictions and rights-of-way of record, if any.
and will warrant and defend the same.
Dated this day of hmg.last...................................... , 19.1.1.
04!'J...(SEAL) ~Qlrt~~E4 ..C-A. ie✓ .........................(3EAL)
• Randall W. Synan ~ Patricia Synan
..............................................-••....................(SEAL) ....................................................................(SEAL)
r. AUTURNTICATION ACZXOWLBDOMZNT
r I
SI ature s STATE OF WLIM13IN
St.
.._...Croix counts
1
J authenticated this ........day of . 19...... Peeeonaft cam before me ---....day of
•A August~_• 19........ the above named
Randall. .W:...S
TITLE: MEMBER STATE BAR OF WISCONSIN S~nan • i
(If not . Aft . ~/~arr~
authorized by 1 706.06. Wis. Stata.) to me known to be the person .2.....Aywa0 ~7t he i
11 /IS~/ii
1 in tnstru at and n Wis i
1
THIS INSTRUMENT WAS DRAFTED BY
'
r Rristina Ogland
Atcarnep..a~t--taw............................... • Alice Joy o ors
i
st; cr10s.X
* Notary Public County, Wis.
l~ (Signatures may be authenticated or acknowledged. Both My Commission is permanent. i not, state exp' stion
are not necessary.) t~
date : ............................1....... In-Lf
1 •Noo o of persons ,ie•inr in any capaelty ekould be typal or printed below "Ir eignAtiseo.
WARRANTT DRED STATIC BAR Of WISCONSIN Wiseomin Lord Bunt Co. Inc
FORM No. 1 - 1913 Milwaukee. WIS.